Reference no: EM133823785

Problem

Computer-assisted coding software has generated a possible list of codes for the following case. Compare the documentation in the case to the list of possible diagnosis, procedure, and service codes generated by the CAC software. (You will need to look up the CPT codes in your coding manual.) Then select the codes that are supported by the documentation in the case. Case: 54-year-old female patient with recently diagnosed Cushing's syndrome who is scheduled for transsphenoidal surgery presents today with complaints of fever, muscle pain, and difficulty breathing. She states she thinks it is just a common cold, but she is anxious about other possibilities due to the recent diagnosis of Cushing's and the upcoming surgery. She wants to "cover all bases and be evaluated to determine if there is something else going on." A medically appropriate history and/or physical exam and high level of medical decision making emergency department evaluation and management services were provided, and results indicated the patient does indeed have a common cold. The patient was provided with instructions about how to relieve her cold symptoms.